CAnswer Forum & Staging Questions Edition...•How to find question in CAnswer Forum by number in...

Validating science. Improving patient care.

No materials in this presentation may be repurposed in print or online without the express written permission of the American Joint Committee on Cancer. Permission requests may be submitted at cancerstaging.org. No materials in this presentation may be repurposed in print or online without the express written permission of the American Joint Committee on Cancer. Permission requests may be submitted at cancerstaging.org.

AJCC 8th Edition Staging CAnswer Forum & Staging Questions Donna M. Gress, RHIT, CTR Technical Editor, AJCC Cancer Staging Manual First Author, Chapter 1: Principles of Cancer Staging

This webinar is sponsored by

The Centers for Disease Control and Prevention

Supported by the Cooperative Agreement Number DP13-1310

National Program of Cancer Registries National Center for Chronic Disease Prevention and Health Promotion

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Copyright © 2018 AJCC All Rights Reserved 3

Learning Objectives

• Examine search techniques for CAnswer Forum

• Discover correct CAnswer Forum for your question

• Dissect types of questions answered in forums

– General rules applied to all cases

– Guidance for specific rare scenarios only

• Develop new knowledge while inspecting forum function

– Identify staging rule explanations

– Choose correct resource for your question, finding answers


Learning Assessments

• Testing effect or retrieval practice – Testing yourself on idea or concept to help you remember it

• Many experts have agreed for centuries

– Act of retrieving info over and over, makes it retrievable when needed – Aristotle: exercise in repeatedly recalling strengthens memory

• Why retrieval/quizzing slows forgetting, helps remembering

– Memory is dynamic (keeps changing), retrieval helps it change – Test often for better results

• Quizzes

– Pretest as part of registration – Quiz during lecture – Posttest emailed weeks later to assess retention – Also assesses clarity of instruction and instructor

CAnswer Forum Usage and Resources


Need Help with Staging?

• CAnswer Forum may provide assistance

• Search first before posting new question

– Your question may already be posted – Find answers fast

• Please start new post if topic is different – Posting new question in unrelated post is confusing – Especially confusing if question is similar

• Post in correct forum so others may find it


Which Forum is Right Forum?

• How to determine where to post, what forum is right?

– Type of question

– Who writes rules on that question

– What book do you use to code or stage

– Pick appropriate subforum


CAnswer Forum Searches

• Home page includes guide document – Click on CAanswer Forum Guide – “Navigating the CAnswer Forum”

• Searching

– Click on down arrow in search box – Select “Advanced Search”

• Advanced Search allows choice of

– Specific forums – Keywords – Specified users



• Choose main forum or subforums

• Choose members



• Keyword-based boolean search – Multiple keywords but not specific phrases – Default comparison

• ‘AND’ • Must contain all keywords

• May use operators

– AND (default) – OR – NOT – - (minus sign) for NOT

• Words omitted from search criteria

– Short, common and bad words omitted – Defined by the site administrator



• Excluded Words

– What it does: excludes search results with particular word or phrase

– What to type: bass -fishing

– What you'll get: results about bass not related to fishing

• Multiple Words

– What it does: searches for results including either word

– What to type: vacation London OR Paris

– What you'll get: results with vacation and either London or Paris


Search by Question Number

• How to find question in CAnswer Forum by number in URL

• Forum URL for question titled “quiz” http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging/ajcc-curriculum-for-registrars/general/55860-quiz

• Use question number and word "node" to locate question

http://cancerbulletin.facs.org/forums/node/55860

• Save this URL, replace X with question number

http://cancerbulletin.facs.org/forums/node/x

http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging/ajcc-curriculum-for-registrars/general/55860-quiz

http://cancerbulletin.facs.org/forums/forum/ajcc-tnm-staging/ajcc-curriculum-for-registrars/general/55860-quiz

http://cancerbulletin.facs.org/forums/node/55860

http://cancerbulletin.facs.org/forums/node/x


Rules or Guidance

• Dissect types of questions answered in forums



• Use caution and read answers carefully

– Is it same situation as your case

– Was it answer for that specific situation

– Important to understand context of answers


Nuances and Discern Information

• Develop new knowledge while inspecting forum function – Learn how to use forum, perform searches – Opportunity to also learn from posted answers

• Identify staging rule explanations – Posts provide explanations based on scenarios – Opportunity to gain more thorough understanding of rules

• Choose correct resource for your question, finding answer – Review questions and answers carefully – Similar or differences from your scenario – Author of post, look for avatar (logo) and color logo signature


Registrar Community

• All registrars who posted answers

• Appreciate the help during my absence

• Gratifying to see posts quoting my previous answers • Pleased those answers were helpful

CAnswer Forum Questions


Slide Format

• Questions are in light blue

• Answers are in black


Blank vs. X

• Partial gastrectomy without node dissection, physician stages T2 N0 M0 stage IB. Why is correct answer pNX and not pN blank when physician used cN0 in pathological staging.

• PSA stated as elevated, so you know it was done but info unavailable. Leave blank or use X since it is unknown.

• Difference between physician or registrar not knowing

– pNX – physician did not have information, not assessed – pN blank – registrar had no access to physician info on this

– PSA lowest value (X not available) – not assessed, phy had no info – PSA blank – registrar had no access to physician info


Multiple Metastases pM1

• Lung case imaging diagnostic of brain mets (cM1b). On surgical resection found positive pleural effusion cytology (pM1a).

• Clinical stage is cM1b, pathological stage is pM1b

• Rule states if at least ONE metastatic site is confirmed, then ALL other metastatic sites do not need confirmation

• Assign M according to multiple sites and use p

• Reason is if one site has been proven, it is more likely all other sites are also mets


Multiple Metastases pM1 Rule Wording

• Manual states: …distant metastasis in multiple sites…If clinical evidence of distant metastasis remains in other areas that are not or cannot be microscopically confirmed, cM1 is assigned. Please explain.

• Statement means – If biopsy of metastatic site turned out NOT to be cancer, – But still have clinical evidence in other sites that they contain mets, – You assign cM1

• Just because one biopsy turned out NOT to be cancer,

doesn't negate clinical evidence of other metastasis


Melanoma Thickness Measurement

• What is rationale to record Breslow thickness to nearest 10th of millimeter rather than 100th of millimeter

• Reasons in CAP protocol:

– Impracticality and imprecision of measurements

– Particularly for tumors >1 mm thick

• 20 key melanoma pathologist opinion leaders discussed

– Pathologists should change way Breslow thickness reported

– Can put other measurements in narrative section of report

– We address in greater detail in forthcoming manuscript regarding

pathological issues related to new staging system


Melanoma Rounding

• What to do about rounding for lesions 0.01-0.04mm thick

• This is theoretical problem/concern

• Breslow thickness measured from top of granular layer of epidermis to deepest invasive cell, intervening epidermal cells always included in measurement

– If epidermis normal thickness, Breslow would always be >0.04mm even if only one invasive cell

– Rare occasions, epidermis may be severely atrophic (only few cells thick) and melanoma could be 0.04mm thick or perhaps less

• If tumor 0.01-0.04 in thickness record as 0.1mm thick (can't round down to 0.0)

• Specification will be in updated pathology manuscript


Grade

• What is priority order for coding sarcoma grade when pathologist states grade 1, and for assigning stage group? Pathologist stated grade I but per 2014 grade instructions grade 1 is coded as grade 2 in grade data item.

• Is stage group for AJCC based on grade 1 or grade 2?

• Grade coded according to AJCC chapter specifications

• Assign AJCC stage group based on grade from pathologist, without any conversion

• Registry conversions for grade stop for 2018 forward

• Grade rules changed for 2018, as they proved to skew data and make it unusable for analysis


Diagnostic Workup vs. Resection

• Clarify stage criteria for bladder. TURB is considered resection. In AJCC, cystectomy is pathologic stage criteria and not TURB.

• All surgical procedures are not surgical treatment

• Pathological stage criteria is surgical treatment – Not surgical procedure – Not surgical resection that isn’t definitive treatment – Careful of common phrases (TURB), resection used but not ca Rx

• Surgery codes encompass diagnosis and treatment

• Clinical vs. pathological staging criteria – Diagnostic workup for clinical staging includes sampling not

intended as definitive treatment – Resection for pathological staging must meet surgical resection

criteria for definitive treatment


Neoadjuvant Response

• cT2 cN1 cM0 invasive ductal breast cancer. Neoadjuvant chemo 6 cycles followed by MRM w/axillary dissection. Pathology report is no residual tumor, nodes negative, pTX.

• Neoadjuvant therapy destroyed all tumor, complete response. Correctly assigned ypT0

• ypT0 ypN0 cM0 stage 99

• Entered into new data item for posttherapy staging

• Reminder - must meet criteria for neoadjuvant


Neoadjuvant No Response

• 4.1cm breast tumor cT2. Neoadjuvant chemo 6 months. Post chemo imaging 6.5cm ycT3, no response. Surgical resection path 7.7cm, ypT3. No stage due to progression?

• Assign posttherapy yp staging

• Some patients do not respond to neoadjuvant therapy

• Analysis on response – If no data on cases not responding to neoadjuvant therapy – Data would only show cases that responded – Result in skewed analysis – Would not know effectiveness of neoadjuvant therapy & risk


T0

• Polypectomy (mucosal resection) sigmoid colon with invasion into submucosa, negative margins, cT1 cN0 cM0. Low anterior resection. Path report was no residual, nodes negative, pT0 pN0.

• Pathologist noted pT0 based only on surgical specimen

– Not T category assigned to patient

– Why pathologist can provide helpful info, but not stage patient

• Pathological staging

– Clinical staging + operative findings + resected specimen path

– pT1 pN0 cM0 stage I


cTis & pTis

• AJCC 8th edition defines cTis: "In situ neoplasia identified during the diagnostic work up on a core or incisional biopsy."

• Breast chapter does not indicate any special circumstances. Do we no longer assign clinical pTis for breast, going back to cTis?

• Major change for AJCC 8th edition – All previous editions instructed using pTis for clinical T category – For 8th edition, changed to cTis for clinical T category – Not going back as cTis never allowed in past editions

• In situ neoplasia document

– AJCC website under Education – Registrar – Explains in situ neoplasia and how to assign stage correctly – Discussed in AJCC Registrar education webinar Major Changes


In Situ & Nodal Involvement

• Melanoma wide excision showed in situ and 1/3 nodes positive. Surgeon staged as Tis N1b M0 stage IIIB. Should registry use this?

• Registry must follow AJCC rules, pTis pN1b cM0 stage 99

• Physician assigns stage group for patient care

• Allows for accurate data analysis

– Analysis on stage groups will highlight these cases

– Researchers may then choose to assign stage group in study

– Need to verify if these patients have same outcome as other N1b


Surgery vs. Resection

• If there is no complete resection, just bladder TURB, do we still use pTis or pTa? Many pathologists use the p category.

• CAP protocols only have pathological staging categories

• Surgery vs. resection – All surgical procedures are not treatment – Surgical resection must meet pathological staging criteria – Surgical resection must be treatment

• Must be assigned cTis or cTa

• Remember, pathologist provides helpful information

– But is not assigning stage for patient – Patient stage reserved for managing physician


Uncertainty

• Physician stages uncertain info using lesser category and plans treatment. Registrar cannot use that stage? Physician made decision. Shouldn't registry database reflect patient care?

• Physicians doing data analysis need to know what is factual

• Cases assigned a lesser category – May have worse outcome – Cannot distinguish when analyzing data – Will confound both national and hospital data

• Important to be able to analyze and assess these cases


Staging with Incomplete Information

• What if physicians use cN0 instead of pNX.

• Cases in registry should use pNX – Unless exception allowed in AJCC chapter – Should have appropriate cN0 in clinical stage – Pathological stage group is usually 99

• Physicians analyzing data

– Can choose to add stage groups for their analysis – Need to distinguish from cases with accurate stage groups – Highlights need to check TNM data items, not just stage groups

• Example from breast stage prognostic group tables

– Clinical group different from pathological group for same TNM – cT may have underestimated tumor – cN0 were found to have pN1 on pathological staging


Stage: Patient Care vs. Data Analysis

• What if physicians don’t stage accurately. Shouldn’t registrars copy incorrect info into registry database.

• Our abstracts are not used for patient care. Why do you say wrong staging can affect their care? Unknowns will affect CLP using NCDB reports.

• Registry data used to change AJCC staging system – Changing system on non-factual data could affect future patient care – Also affects research and analysis using registry data

• Unknown stage groups are opportunity

– Examine data for frequency of uncertainty or not following rules – Discuss with physicians and cancer committee


Registry Data

• Uncertainty rule will have profound affect on physician QA of cancer registry data. Physicians compare medical record to registry, considering registry data incorrect. Not sure best practice of separate rules for physicians & registrars.

• Rules recommended by physicians – Registry data not used because of these problems – Outcomes didn’t match stage for other cases

• Different needs for physicians and registrars

– Physicians need to care for patients, one at a time, personalized – Registry data needs to be factual for analysis, looking at all cases

• Opportunity to examine frequency of uncertainty rules

– How often staging information is uncertain/unclear – Quality improvement study

Information and Questions on AJCC Staging


AJCC Web site

• https://cancerstaging.org

• Ordering information

– Cancerstaging.net

• General information

– Education

– Articles

– Updates


CAnswer Forum

• Submit questions to AJCC Forum

– NEW 8th Edition Forum

– 7th Edition Forum will remain

– Located within CAnswer Forum

– Provides information for all

– Allows tracking for educational purposes

• http://cancerbulletin.facs.org/forums/

Summary


Summary

• Comprehend search techniques for CAnswer Forum

• Identify correct CAnswer Forum for your question

• Interpret types of questions answered in forums



• Build new knowledge while inspecting forum function

– Identify staging rule explanations

– Choose correct resource for your question, finding answers

Thank you

Donna M. Gress, RHIT, CTR Technical Editor AJCC Cancer Staging Manual First Author, Chapter 1: Principles of Cancer Staging 633 N. Saint Clair, Chicago, IL 60611-3295 cancerstaging.org

No materials in this presentation may be repurposed in print or online without the express written permission of the American Joint Committee on Cancer. Permission requests may be submitted at cancerstaging.org.

This webinar is sponsored by

The Centers for Disease Control and Prevention

Supported by the Cooperative Agreement Number DP13-1310

National Program of Cancer Registries National Center for Chronic Disease Prevention and Health Promotion

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

CAnswer Forum & Staging Questions Edition...•How to find question in CAnswer Forum by number in...

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